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Hamid MAB, Sehbai AS, Tariq S. Ischemic Stroke in a Young Man: Unraveling the Domain of Myeloproliferative Disorders. Cureus 2021; 13:e16495. [PMID: 34430110 PMCID: PMC8373526 DOI: 10.7759/cureus.16495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2021] [Indexed: 11/05/2022] Open
Abstract
Ischemic stroke is a rare phenomenon in young adults. A complete workup for hypercoagulable and myeloproliferative disorders is a cornerstone of evaluation. Essential thrombocytosis is a chronic myeloproliferative disorder that primarily involves platelets. It may remain undiagnosed in patients and subsequently present in the form of ischemic stroke. The management of this disorder is complex and often involves cytoreduction therapies. The initiation of these drugs in such patients may lead to unnecessary adverse effects and complications. This case report is an attempt to highlight an underappreciated cause of stroke when assessing young individuals.
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Affiliation(s)
| | - Aasim S Sehbai
- Hematology and Oncology, Alabama Cancer Care, Anniston, USA
| | - Shahan Tariq
- Hematology and Oncology, Alabama Cancer Care, Anniston, USA
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Huang X, Ma T, Zhu Y, Jiao B, Yu S, Wang K, Mi JQ, Ren R. IRF4 and IRF8 expression are associated with clinical phenotype and clinico-hematological response to hydroxyurea in essential thrombocythemia. Front Med 2021; 16:403-415. [PMID: 34331664 DOI: 10.1007/s11684-021-0858-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/08/2021] [Indexed: 01/17/2023]
Abstract
The morbidity and mortality of myeloproliferative neoplasms (MPNs) are primarily caused by arterial and venous complications, progression to myelofibrosis, and transformation to acute leukemia. However, identifying molecular-based biomarkers for risk stratification of patients with MPNs remains a challenge. We have previously shown that interferon regulatory factor-8 (IRF8) and IRF4 serve as tumor suppressors in myeloid cells. In this study, we evaluated the expression of IRF4 and IRF8 and the JAK2V617F mutant allele burden in patients with MPNs. Patients with decreased IRF4 expression were correlated with a more developed MPN phenotype in myelofibrosis (MF) and secondary AML (sAML) transformed from MPNs versus essential thrombocythemia (ET). Negative correlations between the JAK2V617F allele burden and the expression of IRF8 (P < 0.05) and IRF4 (P < 0.001) and between white blood cell (WBC) count and IRF4 expression (P < 0.05) were found in ET patients. IRF8 expression was negatively correlated with the JAK2V617F allele burden (P < 0.05) in polycythemia vera patients. Complete response (CR), partial response (PR), and no response (NR) were observed in 67.5%,10%, and 22.5% of ET patients treated with hydroxyurea (HU), respectively, in 12 months. At 3 months, patients in the CR group showed high IRF4 and IRF8 expression compared with patients in the PR and NR groups. In the 12-month therapy period, low IRF4 and IRF8 expression were independently associated with the unfavorable response to HU and high WBC count. Our data indicate that the expression of IRF4 and IRF8 was associated with the MPN phenotype, which may serve as biomarkers for the response to HU in ET.
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Affiliation(s)
- Xiao Huang
- Shanghai Institute of Hematology, State Key Laboratory for Medical Genomics, Collaborative Innovation Center of Hematology, National Research Center for translational Medicine (Shanghai), Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Tingting Ma
- Shanghai Institute of Hematology, State Key Laboratory for Medical Genomics, Collaborative Innovation Center of Hematology, National Research Center for translational Medicine (Shanghai), Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Yongmei Zhu
- Shanghai Institute of Hematology, State Key Laboratory for Medical Genomics, Collaborative Innovation Center of Hematology, National Research Center for translational Medicine (Shanghai), Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Bo Jiao
- Shanghai Institute of Hematology, State Key Laboratory for Medical Genomics, Collaborative Innovation Center of Hematology, National Research Center for translational Medicine (Shanghai), Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Shanhe Yu
- Shanghai Institute of Hematology, State Key Laboratory for Medical Genomics, Collaborative Innovation Center of Hematology, National Research Center for translational Medicine (Shanghai), Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Kankan Wang
- Shanghai Institute of Hematology, State Key Laboratory for Medical Genomics, Collaborative Innovation Center of Hematology, National Research Center for translational Medicine (Shanghai), Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Jian-Qing Mi
- Shanghai Institute of Hematology, State Key Laboratory for Medical Genomics, Collaborative Innovation Center of Hematology, National Research Center for translational Medicine (Shanghai), Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Ruibao Ren
- Shanghai Institute of Hematology, State Key Laboratory for Medical Genomics, Collaborative Innovation Center of Hematology, National Research Center for translational Medicine (Shanghai), Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
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3
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Nann D, Fend F. Synoptic Diagnostics of Myeloproliferative Neoplasms: Morphology and Molecular Genetics. Cancers (Basel) 2021; 13:cancers13143528. [PMID: 34298741 PMCID: PMC8303289 DOI: 10.3390/cancers13143528] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/06/2021] [Accepted: 07/09/2021] [Indexed: 02/02/2023] Open
Abstract
Simple Summary The diagnosis of myeloproliferative neoplasms requires assessment of a combination of clinical, morphological, immunophenotypic and genetic features, and this integrated, multimodal approach forms the basis for precise classification. Evaluation includes cell counts and morphology in the peripheral blood, bone marrow aspiration and trephine biopsy, and may encompass flow cytometry for specific questions. Diagnosis nowadays is completed by targeted molecular analysis for the detection of recurrent driver and, optionally, disease-modifying mutations. According to the current World Health Organization classification, all myeloproliferative disorders require assessment of molecular features to support the diagnosis or confirm a molecularly defined entity. This requires a structured molecular analysis workflow tailored for a rapid and cost-effective diagnosis. The review focuses on the morphological and molecular features of Ph-negative myeloproliferative neoplasms and their differential diagnoses, addresses open questions of classification, and emphasizes the enduring role of histopathological assessment in the molecular era. Abstract The diagnosis of a myeloid neoplasm relies on a combination of clinical, morphological, immunophenotypic and genetic features, and an integrated, multimodality approach is needed for precise classification. The basic diagnostics of myeloid neoplasms still rely on cell counts and morphology of peripheral blood and bone marrow aspirate, flow cytometry, cytogenetics and bone marrow trephine biopsy, but particularly in the setting of Ph− myeloproliferative neoplasms (MPN), the trephine biopsy has a crucial role. Nowadays, molecular studies are of great importance in confirming or refining a diagnosis and providing prognostic information. All myeloid neoplasms of chronic evolution included in this review, nowadays feature the presence or absence of specific genetic markers in their diagnostic criteria according to the current WHO classification, underlining the importance of molecular studies. Crucial differential diagnoses of Ph− MPN are the category of myeloid/lymphoid neoplasms with eosinophilia and gene rearrangement of PDGFRA, PDGFRB or FGFR1, or with PCM1-JAK2, and myelodysplastic/myeloproliferative neoplasms (MDS/MPN). This review focuses on morphological, immunophenotypical and molecular features of BCR-ABL1-negative MPN and their differential diagnoses. Furthermore, areas of difficulties and open questions in their classification are addressed, and the persistent role of morphology in the area of molecular medicine is discussed.
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Affiliation(s)
- Dominik Nann
- Institute of Pathology and Neuropathology, University Hospital Tübingen, 72076 Tübingen, Germany;
- Comprehensive Cancer Center, University Hospital Tübingen, 72076 Tübingen, Germany
| | - Falko Fend
- Institute of Pathology and Neuropathology, University Hospital Tübingen, 72076 Tübingen, Germany;
- Comprehensive Cancer Center, University Hospital Tübingen, 72076 Tübingen, Germany
- Correspondence: ; Tel.: +49-7071-2980207
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Yuzaki M, Honda K, Kaneko M, Nakai T, Kunimoto H, Nishimura Y. Aortic valve replacement with essential thrombocythemia. Asian Cardiovasc Thorac Ann 2018; 27:118-120. [DOI: 10.1177/0218492318788152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiac surgery in patients with essential thrombocythemia carries the risks of both thrombotic events and a bleeding tendency. We report the case of a 75-year-old man with essential thrombocythemia who underwent successful surgical aortic valve replacement after his platelet count was controlled with plateletpheresis 3 times before surgery.
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Affiliation(s)
- Mitsuru Yuzaki
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, Wakayama, Japan
| | - Kentaro Honda
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, Wakayama, Japan
| | - Masahiro Kaneko
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, Wakayama, Japan
| | - Takeo Nakai
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, Wakayama, Japan
| | - Hideki Kunimoto
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, Wakayama, Japan
| | - Yoshiharu Nishimura
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, Wakayama, Japan
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Thrombocytapheresis: Managing Essential Thrombocythemia in a Surgical Patient. Ann Thorac Surg 2011; 92:e5-6. [DOI: 10.1016/j.athoracsur.2011.02.050] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2010] [Revised: 02/12/2011] [Accepted: 02/16/2011] [Indexed: 11/22/2022]
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Bang SM, Kim HY, Kim HJ, Kim HJ, Won JH, Kim BS, Jung CW, Chi HS. Diagnostic and therapeutic guideline for myeloproliferative neoplasm. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2011. [DOI: 10.5124/jkma.2011.54.1.112] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ho Young Kim
- Department of Internal Medicine, Hallym University Medical Center, Anyang, Seoul, Korea
| | - Hyo Jung Kim
- Department of Internal Medicine, Hallym University Medical Center, Anyang, Seoul, Korea
| | - Hee-Jin Kim
- Department of Laboratory Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Ho Won
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Bong Seog Kim
- Department of Internal Medicine, Seoul Veterans Hospital, Seoul, Korea
| | - Chul-Won Jung
- Department of Internal Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun-Sook Chi
- Department of Laboratory Medicine, University of Ulsan College of Medicine, Seoul, Korea
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Thiele J. Philadelphia chromosome-negative chronic myeloproliferative disease. Am J Clin Pathol 2009; 132:261-80. [PMID: 19605821 DOI: 10.1309/ajcpr8ginmbdg9yg] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Session 2 of the 2007 Workshop of the Society for Hematopathology/European Association for Haematopathology was focused on Philadelphia chromosome-negative chronic myeloproliferative diseases (Ph- MPDs), recently termed chronic myeloproliferative neoplasms. The presented and submitted cases highlighted some important issues and also impending problems associated with the diagnosis and classification. Cases included predominantly rare entities like chronic eosinophilic leukemia and related disorders, chronic neutrophilic leukemia, and others with specific genetic abnormalities that allowed molecularly targeted therapy. In this context, the distinctive role of a positive JAK2(V617F) mutation for the diagnosis of Ph- MPD was underscored, including entities with a low allele burden and the discrimination from reactive disorders (autoimmune myelofibrosis, reactive thrombocytosis). Although novel genetic and molecular approaches have significantly improved the way we classify Ph- MPD, a combined clinicopathologic approach, including representative bone marrow specimens, still remains the yardstick for diagnosis.
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Blann A, Caine G, Bareford D. Abnormal vascular, platelet and coagulation markers in primary thrombocythaemia are not reversed by treatments that reduce the platelet count. Platelets 2009; 15:447-9. [PMID: 15745316 DOI: 10.1080/09537100412331272541] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Although the primary aim of the treatment of primary thrombocythaemia is to reduce platelet counts, its effect on platelet activation, vascular dysfunction and coagulopathy, which are also abnormal, is unknown. We therefore hypothesised that successful treatment of primary thrombocythaemia is accompanied by an improvement in markers of these processes. To test this hypothesis, we compared 38 patients with 15 healthy age and sex-matched controls. Seven untreated patients had platelet counts higher than those 31 on treatment, that were in turn higher than the 15 controls (all p < 0.01). Plasma fibrinogen, P-selectin, von Willebrand factor and sVCAM were higher in both patient groups compared to controls (all p < 0.05), but not between patient groups. sE-selectin and sICAM were unaltered between the three groups. D-dimers were higher in treated patients than in controls. We conclude that successful thrombocytosis treatment does not normalise markers of coagulation, platelet, or endothelial pathophysiology. This may account for continuing risk of pathology in those whose platelet counts have been normalised.
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Affiliation(s)
- Andrew Blann
- University Department of Medicine, Haematology City Hospital, Dudley Road Birmingham, B18 7QH, UK.
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Nakatani T, Imamura T, Ishida H, Wakaizumi K, Yamamoto T, Otabe O, Ishigami T, Adachi S, Morimoto A. Frequency and clinical features of the JAK2 V617F mutation in pediatric patients with sporadic essential thrombocythemia. Pediatr Blood Cancer 2008; 51:802-5. [PMID: 18802948 DOI: 10.1002/pbc.21730] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Pediatric essential thrombocythemia (ET) is a rare and heterogenous disease entity. While several recent studies have focused on the role of the JAK2 V617F mutation in pediatric ET, the frequency of pediatric ET cases with this mutation and the associated clinical features remain unclear. PROCEDURE We examined six childhood cases who had been diagnosed with ET according to WHO criteria (onset age: 0.2-14 years) for the presence of the JAK2 V617F mutation, MPLW515L mutation and JAK2 exon 12 mutations. Two sensitive PCR-based methods were used for the JAK2 V617F genotyping. We also examined the expression of polycythemia rubra vera-1 (PRV-1), which is a diagnostic marker for clonal ET. RESULTS We found that three of the six cases had the JAK2 V617F mutation and that all six cases expressed PRV-1 in their peripheral granulocytes. Neither MPL W515L mutation nor JAK2 exon 12 mutations was detected in the patients without JAK2 V617F mutation. The two patients who developed thrombocythemia during infancy were JAK2 V617F-negative. CONCLUSIONS These findings suggest that the JAK2 V617F mutation is not rare in childhood sporadic ET cases, and that these cases might be older and myeloproliferative features.
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Affiliation(s)
- Takuya Nakatani
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
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Kvasnicka HM, Thiele J. Classification of Ph-Negative Chronic Myeloproliferative Disorders – Morphology as the Yardstick of Classification. Pathobiology 2007; 74:63-71. [PMID: 17587877 DOI: 10.1159/000101706] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Histopathology of bone marrow (BM) biopsies plays a crucial role in the interdisciplinary approach to diagnosis and classification of Ph-negative chronic myeloproliferative disorders. Based on careful clinicopathologic studies, BM features are critical determinants that help to predict overall prognosis, to detect complications such as progression to myelofibrosis and blast crisis, and to assess therapy-related changes. METHODS AND RESULTS A systematic evaluation of BM histopathology allows an objective identification of cases of (true) essential thrombocythemia and their separation from early prefibrotic stages of chronic idiopathic myelofibrosis. By follow-up examinations that include BM biopsies, the progression of the disease process is unveiled, which is especially important for patients with initial polycythemia vera and prefibrotic chronic idiopathic myelofibrosis that may require a different therapeutic approach than the full-blown stages. CONCLUSION BM biopsy should be considered as major diagnostic tool for evaluation and follow-up of patients enrolled in prospective studies.
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Miller JF, Biondi-Zoccai GGL, Abbate A. Essential thrombocythemia presenting as unstable angina pectoris: what should the cardiologist know? Int J Cardiol 2007; 114:E35. [PMID: 16889850 DOI: 10.1016/j.ijcard.2006.05.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2006] [Accepted: 05/26/2006] [Indexed: 02/08/2023]
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Thiele J, Kvasnicka HM. A critical reappraisal of the WHO classification of the chronic myeloproliferative disorders. Leuk Lymphoma 2006; 47:381-96. [PMID: 16396760 DOI: 10.1080/10428190500331329] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Following the introduction of the WHO classification of chronic myeloproliferative disorders (MPDs), after approximately 5 years, a critical reappraisal appears to be warranted. Retrospective clinico-pathological evaluations conducted in the meantime, as well as the detection of new biomarkers, may aid in testing the validity of these new criteria. Based on a large series of patients with chronic myeloid leukemia (CML), an analysis of bone marrow (BM) features and risk classifications revealed that the fiber content exerted a most important and independent impact on prognosis. This finding was also supported in a prospective randomized study and therefore myelofibrosis should be included in any staging system in CML related to survival. Moreover, it is important to emphasize the dynamics of the disease process in MPDs, especially in polycythemia vera (PV) and chronic idiopathic myelofibrosis (CIMF). Latent-stage PV is difficult to recognize when adhering to the proposed limits for hemoglobin (or red cell mass) without regarding the erythropoietin (EPO) level, endogenous erythroid colonies (EECs) or BM histopathology. Initial PV may firstly present with complications and, when accompanied by a high platelet count, mimics essential thrombocythemia (ET). Consequently, BM morphology and EPO level should be entered as major diagnostic criteria for PV. To document more accurately the progress of disease, a simplified scoring system concerning myelofibrosis has to be included in the histological description of CIMF. The diagnostic guidelines of BM features in ET should be improved because, usually, there is neither a significant proliferation nor left-shifting of the granulo- and erythropoiesis detectable and no relevant increase in reticulin. A comparison of clinical data and BM morphology reveals that biomarkers (EPO, EECs, PRV-1, JAK2) show an overlapping pattern of positivity between the different subtypes of MPDs.
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MESH Headings
- Chronic Disease
- Disease Progression
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/classification
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/pathology
- Myeloproliferative Disorders/classification
- Myeloproliferative Disorders/diagnosis
- Myeloproliferative Disorders/pathology
- Primary Myelofibrosis/classification
- Primary Myelofibrosis/diagnosis
- Primary Myelofibrosis/pathology
- Retrospective Studies
- Thrombocythemia, Essential/classification
- Thrombocythemia, Essential/diagnosis
- Thrombocythemia, Essential/pathology
- World Health Organization
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Affiliation(s)
- Juergen Thiele
- Institute of Pathology, University Cologne, Cologne, Germany.
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Balasubramaniam R, Van Sickels J, Falace D. Condylar resorption following temporomandibular joint arthroscopy in a patient with essential thrombocythemia. ACTA ACUST UNITED AC 2006; 101:581-7. [PMID: 16632268 DOI: 10.1016/j.tripleo.2005.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2005] [Revised: 06/16/2005] [Accepted: 07/01/2005] [Indexed: 11/16/2022]
Abstract
Condylar resorption of the temporomandibular joint (TMJ) is a poorly understood phenomenon that is the subject of much controversy. The following case report depicts a unique case of condylar resorption (CR) in a 49-year-old female patient with essential thrombocythemia who underwent arthrocentesis of the TMJ. The exact cause of the CR is unclear but it is speculated that it was likely due to hemorrhagic and thrombotic complications during surgery secondary to an elevated platelet count.
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Affiliation(s)
- Ramesh Balasubramaniam
- Orofacial Pain, Orofacial Pain Center, College of Dentistry, University of Kentucky, Lexington, Kentucky 40536-0297, USA.
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Campbell PJ, Scott LM, Buck G, Wheatley K, East CL, Marsden JT, Duffy A, Boyd EM, Bench AJ, Scott MA, Vassiliou GS, Milligan DW, Smith SR, Erber WN, Bareford D, Wilkins BS, Reilly JT, Harrison CN, Green AR. Definition of subtypes of essential thrombocythaemia and relation to polycythaemia vera based on JAK2 V617F mutation status: a prospective study. Lancet 2005; 366:1945-53. [PMID: 16325696 DOI: 10.1016/s0140-6736(05)67785-9] [Citation(s) in RCA: 516] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND An acquired V617F mutation in JAK2 occurs in most patients with polycythaemia vera, but is seen in only half those with essential thrombocythaemia and idiopathic myelofibrosis. We aimed to assess whether patients with the mutation are biologically distinct from those without, and why the same mutation is associated with different disease phenotypes. METHODS Two sensitive PCR-based methods were used to assess the JAK2 mutation status of 806 patients with essential thrombocythaemia, including 776 from the Medical Research Council's Primary Thrombocythaemia trial (MRC PT-1) and two other prospective studies. Laboratory and clinical features, response to treatment, and clinical events were compared for V617F-positive and V617F-negative patients with essential thrombocythaemia. FINDINGS Mutation-positive patients had multiple features resembling polycythaemia vera, with significantly increased haemoglobin (mean increase 9.6 g/L, 95% CI 7.6-11.6 g/L; p<0.0001), neutrophil counts (1.1x10(9)/L, 0.7-1.5x10(9)/L; p<0.0001), bone marrow erythropoiesis and granulopoiesis, more venous thromboses, and a higher rate of polycythaemic transformation than those without the mutation. Mutation-positive patients had lower serum erythropoietin (mean decrease 13.8 U/L; 95% CI, 10.8-16.9 U/L; p<0.0001) and ferritin (n=182; median 58 vs 91 mug/L; p=0.01) concentrations than did mutation-negative patients. Mutation-negative patients did, nonetheless, show many clinical and laboratory features that were characteristic of a myeloproliferative disorder. V617F-positive individuals were more sensitive to therapy with hydroxyurea, but not anagrelide, than those without the JAK2 mutation. INTERPRETATION Our results suggest that JAK2 V617F-positive essential thrombocythaemia and polycythaemia vera form a biological continuum, with the degree of erythrocytosis determined by physiological or genetic modifiers.
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Abstract
Significant progress in our understanding of the molecular pathogenesis of essential thrombocythemia (ET) and the other Philadelphia (Ph) chromosome-negative myeloproliferative disorders (MPDs) has recently been achieved. Unfortunately, the diagnosis of ET still relies on a set of exclusion criteria developed years ago, as recent advances have yet to be evaluated for this purpose. The clinical course of ET is characterized by an increased incidence of thrombotic and hemorrhagic complications and an inherent tendency to progress into myelofibrosis or acute myeloid leukemia (AML). There is concern about undesirable effects of cytoreductive therapy given to prevent vascular events, particularly the risk of accelerating the rate of hematologic transformation. Thus, management involves modification of reversible vascular risk factors and further stratification according to the thrombotic risk. Myelosuppressive agents are not recommended in low-risk patients, whereas controlled studies support the therapeutic value of hydroxyurea (HU) plus aspirin in high-risk cases. Anagrelide or interferon-alpha (IFN-alpha) could be considered as second-line therapy in patients refractory or intolerant of HU. IFN-alpha is preferred in pregnant women.
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Affiliation(s)
- Guido Finazzi
- Department of Hematology, Ospedali Riuniti, Largo Barozzi 1, 24128 Bergamo, Italy.
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Thiele J, Kvasnicka HM, Orazi A. Bone Marrow Histopathology in Myeloproliferative Disorders—Current Diagnostic Approach. Semin Hematol 2005; 42:184-95. [PMID: 16210032 DOI: 10.1053/j.seminhematol.2005.05.020] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Current diagnostic issues in chronic myeloproliferative disorders (MPDs) include the differentiation of essential thrombocythemia (ET) from its mimics: early (prefibrotic) stages of chronic idiopathic myelofibrosis (CIMF) and early polycythemia vera (PV), both of which can be associated with thrombocytosis. Applying a systematic evaluation of bone marrow histopathology, in accordance with the current World Health Organization (WHO) classification system, it is possible to identify cases of true ET as opposed to false ET, usually early-stage CIMF accompanied by an excess of platelets. This distinction is important because the frequency of complications such as progression to overt myelofibrosis, blastic crisis, and overall prognosis are significantly different in the two conditions. The diagnostic criteria of the Polycythemia Vera Study Group (PVSG) do not adequately define the initial stages of PV, nor do they distinguish PV with thrombocytosis from ET. Differentiation of the two is possible by bone marrow histopathology, which also is highly predictive (96%) in distinguishing PV from secondary polycythemia. In conclusion, bone marrow biopsy is an important diagnostic tool for distinguishing specific subtypes of MPD and should be a mandatory step for entry evaluation and follow-up of patients enrolled in prospective studies and/or clinical trials.
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Affiliation(s)
- Juergen Thiele
- Institute of Pathology, Cologne University, Joseph-Stelzmann-Strasse 9, D-50924 Cologne, Germany.
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Abstract
Myeloproliferative disorders are characterized by overproduction of one or more blood lineages. The clinical course of the Philadelphia-negative myeloproliferative disorders, particularly essential thrombocythemia and polycythemia vera, are characterized by vascular symptoms and in the long-term, transformation to myelofibrosis and leukemia may occur. Control of myeloproliferation has traditionally been achieved using cytotoxic agents but many of these have a documented ability to increase the risk of leukemia. Anagrelide, initially developed as an antiaggregant, is an attractive alternative to these agents as it appears to be relatively selective in reducing the platelet count and is unlikely to be leukemogenic. This article reviews clinical studies in these patients and discusses the future scope for anagrelide.
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Affiliation(s)
- Claire N Harrison
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, Lambeth Palace Road, London, UK.
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Harrison CN, Campbell PJ, Buck G, Wheatley K, East CL, Bareford D, Wilkins BS, van der Walt JD, Reilly JT, Grigg AP, Revell P, Woodcock BE, Green AR. Hydroxyurea compared with anagrelide in high-risk essential thrombocythemia. N Engl J Med 2005; 353:33-45. [PMID: 16000354 DOI: 10.1056/nejmoa043800] [Citation(s) in RCA: 592] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND We conducted a randomized comparison of hydroxyurea with anagrelide in the treatment of essential thrombocythemia. METHODS A total of 809 patients with essential thrombocythemia who were at high risk for vascular events received low-dose aspirin plus either anagrelide or hydroxyurea. The composite primary end point was the actuarial risk of arterial thrombosis (myocardial infarction, unstable angina, cerebrovascular accident, transient ischemic attack, or peripheral arterial thrombosis), venous thrombosis (deep-vein thrombosis, splanchnic-vein thrombosis, or pulmonary embolism), serious hemorrhage, or death from thrombotic or hemorrhagic causes. RESULTS After a median follow-up of 39 months, patients in the anagrelide group were significantly more likely than those in the hydroxyurea group to have reached the primary end point (odds ratio, 1.57; 95 percent confidence interval, 1.04 to 2.37; P=0.03). As compared with hydroxyurea plus aspirin, anagrelide plus aspirin was associated with increased rates of arterial thrombosis (P=0.004), serious hemorrhage (P=0.008), and transformation to myelofibrosis (P=0.01) but with a decreased rate of venous thromboembolism (P=0.006). Patients receiving anagrelide were more likely to withdraw from their assigned treatment (P<0.001). Equivalent long-term control of the platelet count was achieved in both groups. CONCLUSIONS Hydroxyurea plus low-dose aspirin is superior to anagrelide plus low-dose aspirin for patients with essential thrombocythemia at high risk for vascular events.
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Affiliation(s)
- Claire N Harrison
- Department of Haematology, University of Cambridge, and Addenbrooke's National Health Service Trust, Cambridge, United Kingdom
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Baxter EJ, Scott LM, Campbell PJ, East C, Fourouclas N, Swanton S, Vassiliou GS, Bench AJ, Boyd EM, Curtin N, Scott MA, Erber WN, Green AR. Acquired mutation of the tyrosine kinase JAK2 in human myeloproliferative disorders. Lancet 2005; 365:1054-61. [PMID: 15781101 DOI: 10.1016/s0140-6736(05)71142-9] [Citation(s) in RCA: 1986] [Impact Index Per Article: 104.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Human myeloproliferative disorders form a range of clonal haematological malignant diseases, the main members of which are polycythaemia vera, essential thrombocythaemia, and idiopathic myelofibrosis. The molecular pathogenesis of these disorders is unknown, but tyrosine kinases have been implicated in several related disorders. We investigated the role of the cytoplasmic tyrosine kinase JAK2 in patients with a myeloproliferative disorder. METHODS We obtained DNA samples from patients with polycythaemia vera, essential thrombocythaemia, or idiopathic myelofibrosis. The coding exons of JAK2 were bidirectionally sequenced from peripheral-blood granulocytes, T cells, or both. Allele-specific PCR, molecular cytogenetic studies, microsatellite PCR, Affymetrix single nucleotide polymorphism array analyses, and colony assays were undertaken on subgroups of patients. FINDINGS A single point mutation (Val617Phe) was identified in JAK2 in 71 (97%) of 73 patients with polycythaemia vera, 29 (57%) of 51 with essential thrombocythaemia, and eight (50%) of 16 with idiopathic myelofibrosis. The mutation is acquired, is present in a variable proportion of granulocytes, alters a highly conserved valine present in the negative regulatory JH2 domain, and is predicted to dysregulate kinase activity. It was heterozygous in most patients, homozygous in a subset as a result of mitotic recombination, and arose in a multipotent progenitor capable of giving rise to erythroid and myeloid cells. The mutation was present in all erythropoietin-independent erythroid colonies. INTERPRETATION A single acquired mutation of JAK2 was noted in more than half of patients with a myeloproliferative disorder. Its presence in all erythropoietin-independent erythroid colonies demonstrates a link with growth factor hypersensitivity, a key biological feature of these disorders. RELEVANCE TO PRACTICE Identification of the Val617Phe JAK2 mutation lays the foundation for new approaches to the diagnosis, classification, and treatment of myeloproliferative disorders.
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Affiliation(s)
- E Joanna Baxter
- Department of Haematology, Cambridge Institute for Medical Research, University of Cambridge, Cambridge, UK
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Randi ML, Putti MC, Pacquola E, Luzzatto G, Zanesco L, Fabris F. Normal thrombopoietin and its receptor (c-mpl) genes in children with essential thrombocythemia. Pediatr Blood Cancer 2005; 44:47-50. [PMID: 15390356 DOI: 10.1002/pbc.20185] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Following the observation of thrombopoietin (TPO) gene abnormalities as the cause of familiar cases of thrombocythemia similar derangements of TPO and/or its receptor (c-mpl) might be surmised to be at the root of increased platelet count also in non-familiar (sporadic) cases. Although this was not demonstrated in adults, little data exist about childhood. PROCEDURES We studied the molecular biology of TPO and c-mpl in seven children with non-familiar essential thrombocythemia (ET) and one child with secondary thrombocytosis (ST). Plasma TPO content was measured using a commercially available kit. Genomic DNA was extracted from whole blood by standard methods and TPO and c-mpl genes were amplified by polymerase chain reaction (PCR) and sequenced. RESULTS Plasma TPO levels were normal in all our patients. No alteration was detected in either coding region, including the flanking intronic sequences of TPO and c-mpl genes. As compared to the published normal sequence of the TPO gene, one allelic base change in a non-coding region of intron 1 was found in all children with ET and ST, but this was reported as a common finding in normal subjects as well. CONCLUSIONS High platelet count in our series of sporadic ET of childhood is not due to an abnormality either of TPO or c-mpl gene.
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Affiliation(s)
- M L Randi
- Department of Medical and Surgical Sciences, University of Padua Medical School, Padua, Italy.
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Campbell PJ, Green AR. Management of polycythemia vera and essential thrombocythemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2005:201-8. [PMID: 16304381 DOI: 10.1182/asheducation-2005.1.201] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
The optimal management of patients with polycythemia vera (PV) and essential thrombocythemia (ET) continues to be controversial. Both diseases present diagnostic challenges and there is a paucity of data from randomized clinical trials to guide therapeutic decisions. However, the past two years have seen major advances in our understanding of these myeloproliferative disorders (MPD). First, the ECLAP study demonstrated the anti-thrombotic efficacy of aspirin in patients with PV. Second, the PT-1 trial, the largest randomized study of any MPD, has provided much needed guidance on the optimal management of patients with ET. Third, the identification of a single JAK2 mutation in most patients with PV, and in some of those with ET, illuminates the pathogenesis of these diseases and raises questions about the boundary between them. For the purpose of management decisions, it remains appropriate to consider them as separate entities for the time being. However, as we learn more about the clinical significance of the JAK2 mutation, it seems likely that the coming years will see major changes in the way we classify and manage these disorders.
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Affiliation(s)
- Peter J Campbell
- University of Cambridge Department of Haematology, Cambridge Institute for Medical Research, Cambridge, CB2 2XY, UK
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